Precautions for Abdominal Paracentesis

Stop anticoagulation – 3 days prior for warfarin and 1 day prior for subcutaneous heparin.

Coagulopathy is no more regarded as a contraindication for ascitic tapping. However, some authors recommend considering Fresh Frozen Plasma (FFP) or Platelet concentrates for INR >2 and Platelet count <20,000 respectively despite scanty evidence, to support safety of patient.3Manual of ICU Procedures By Mohan Gurjar

Percuss the area of dullness.

Make sure the spleen is not palpable.

Catheterization of distended urinary bladder.

Nasogastric decompression in case of bowel obstruction.

Needle entry sites to Avoid

Avoid anatomical landmark for inferior epigastric artery which traces from a point just lateral to the pubic tubercle (which is 2 to 3 cm lateral to the symphysis pubis), cephalad (upward) within the rectus sheath.

Avoid areas of skin infection.

Avoid areas near surgical scars.

Avoid visibly engorged veins (likely to be present in patients with liver disease).

Preferred Needle entry site

1. Selected site for needle entry must always be lateral to the rectus abdominis muscle to prevent puncturing inferior epigastric artery as described earlier.

2. Shifting dullness (percussing for resonance and moving laterally until dullness is percussed) is used to identify areas of fluid for paracentesis.

5. Infraumbilical midline approach: The site 2 cm below the umbilicus was used previously as it was along the linea alba which is devoid of vessles. However, this approach has been abandoned now as one laparoscopic study found that in patients with portal hypertension there are collaterals in the midline which can rupture during paracentesis.5Paracentesis by Arun J. Sanyala, Jasmohan S. Bajaja, Jawaid Shawc Also, the recanalized umbilical vein may be present caudad to the umbilicus in the midline, an area that should be avoided.

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